Deficiencies per Year
4
3
2
1
0
High
Unclassified
Inspection Report
Original Licensing
Deficiencies: 1
Sep 19, 2025
Visit Reason
Original investigation of facility FRI IL 197269 to assess compliance with resident rights regulations.
Findings
The facility was found to have neglected one of three residents experiencing pain and vomiting, resulting in a Type 2 violation due to failure to provide necessary care and medical attention overnight.
Severity Breakdown
Type 2 VIOLATION: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to address one of three residents experiencing pain and vomiting, resulting in substantial probability of harm. | Type 2 VIOLATION |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Caregiver | Named in failure to follow protocol leading to resident pain and vomiting overnight. |
| E1 | Executive Director | Expressed concerns about failure to follow protocol and stated termination of E3. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation following substantiated incidents involving controlled medication misappropriation and failure to follow medication storage and supervision policies.
Findings
The facility failed to follow its policy and procedure on controlled medication storage and supervision, resulting in missing controlled substances (Morphine and Lorazepam) from residents' comfort kits. Narcotic lock boxes were stored in unlocked resident refrigerators, accessible to others, and shift-to-shift counts of controlled substances were not consistently performed. The incidents were reported to police but the establishment could not identify who took the medications.
Complaint Details
The complaint investigation was substantiated with findings of missing controlled substances from residents R16 and R17. The investigation revealed missing Morphine and Lorazepam, with evidence of tampering and missing narcotic sheets. The incidents were reported to police.
Severity Breakdown
Type 2 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow policy and procedure on controlled medication storage and supervision, including storing narcotic lock boxes in unlocked resident refrigerators accessible to others. | Type 2 Violation |
| Failure to prevent misappropriation of controlled medications paid for by residents, resulting in missing Morphine and Lorazepam from residents' comfort kits. | Type 2 Violation |
Report Facts
Milliliters of Morphine missing: 28.75
Milliliters of Lorazepam missing: 19.25
Milliliters of Morphine missing: 30
Milliliters of Morphine in lock box: 29.75
Milliliters of Lorazepam in lock box: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Director of Assisted Living and Memory Care | Provided information about medication storage practices and missing Morphine for resident R17 |
| E4 | Nurse | Provided information about narcotic counts and medication administration during the investigation |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 5, 2025
Visit Reason
Investigation of a self-reported incident related to medication administration at Lexington Square of Lombard.
Findings
A violation of Section 295.5000 & 295.6000 regarding medication administration was cited. The facility has implemented enhanced security and monitoring protocols for hospice comfort kit medications, including weekly audits and a double-lock security system.
Deficiencies (1)
| Description |
|---|
| Violation of Section 295.5000 & 295.6000 Medication Administration |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carlos Bernal | Executive Director | Signed the plan of correction letter addressing medication administration violation. |
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